View source for EBQ:Worst headache and subarachnoid hemorrhage

{{JC info
| title= Headache Characteristics in Subarachnoid Haemorrhage and Benign Thunderclap Headache
| abbreviation= 
| expansion= 
| published= 1998
| author= Linn FH, Wijdicks EF, van der Graaf Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J.
| journal= J Neurol Neurosurg Psychiatry
| year= 1998
| volume= 65
| issue= 5
| pages= 791-793
| pmid= 9737490
| fulltexturl= 
| pdfurl= 
| status = Complete
}}

==Clinical Question==
Can "worst headache of life" or specific headache characteristics reliably distinguish subarachnoid hemorrhage from benign thunderclap headache?

==Conclusion==
*No single headache characteristic reliably distinguishes SAH from benign thunderclap headache
*"Worst headache of life" alone has poor specificity for SAH
*Further diagnostic workup (CT, LP) is required regardless of headache characteristics when SAH is suspected

==Major Points==
*The study compared headache features in patients with confirmed SAH vs benign thunderclap headache
*Headache severity, onset pattern (sudden vs gradual), associated symptoms (nausea, vomiting, LOC) overlapped significantly between groups
*Approximately 12% of patients presenting with "worst headache" had SAH
*Neither the location nor the quality of headache was discriminating
*The study reinforced the need for objective diagnostic testing (CT followed by LP if CT negative) rather than relying on headache phenomenology

==Study Design==
*Prospective cohort study
*University Medical Center Utrecht, Netherlands
*N = 148 patients with sudden severe headache
*All patients underwent CT and lumbar puncture
*Primary Outcome: headache characteristics that discriminate SAH from benign thunderclap headache

==Population==
===Inclusion Criteria===
*Adults presenting with sudden onset severe headache (thunderclap headache)
*Headache reaching maximal intensity within seconds to minutes
===Exclusion Criteria===
*Headache with obvious secondary cause other than SAH (e.g., meningitis, trauma)
*Recurrent primary headache disorders with typical pattern

==Interventions==
*No therapeutic intervention; diagnostic accuracy study
*All patients underwent standardized headache assessment, non-contrast CT head, and lumbar puncture
*SAH was confirmed by CT findings or xanthochromia on CSF analysis

==Outcomes==
===Primary Outcome===
*No headache characteristic was independently predictive of SAH vs benign thunderclap headache
*Proportion with SAH: approximately 12% of patients with worst headache
===Secondary Outcomes===
*Overlap in headache features between SAH and benign thunderclap headache:
**Sudden onset: present in both groups
**Occipital location: similar frequency
**Associated neck stiffness: more common in SAH but present in benign thunderclap
**Vomiting: more common in SAH but not discriminating

==Criticisms==
*Relatively small sample size limits statistical power for subgroup analyses
*Single-center study in a Dutch referral population
*The definition of "thunderclap headache" may vary between practitioners
*Selection bias: patients with milder headaches who may represent earlier SAH presentations may not have been included
*The study did not evaluate modern risk stratification tools (e.g., Ottawa SAH Rule)

==Funding==
*Netherlands Heart Foundation

==See Also==
*[[Subarachnoid hemorrhage]]
*[[Thunderclap headache]]
*[[EBQ:Perry Subarachnoid Haemorrhage Study]]

==References==
<references/>

[[Category:EBQ]]
[[Category:Neurology]]